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Treatment of AD in Clinical Practice


Experts in dermatology review clinical trials for AD treatment and how this data translates into their own practices.

Jonathan I. Silverberg, MD, PhD, MPH: What outcomes should we be looking at in clinical practice? What should our treatment goals be?

Andrew Blauvelt, MD, MBA: I’m not in practice, but I like to recommend things for practitioners. I say, don’t worry about the EASI [Eczema Area and Severity Index]. EASI is too complicated for clinical practice, even though it’s 1 of the main tools we use in trials.

Jonathan I. Silverberg, MD, PhD, MPH: There’s nothing easy about it.

Andrew Blauvelt, MD, MBA: EASI is not easy. I say that BSA [body surface area] is the most important thing for psoriasis. The vIGA [validated Investigator Global Assessment] is the most important thing for atopic dermatitis practitioners. The BSA for AD can go up and down quickly, but in psoriasis, you can see it steadily improve. I’d like the IGA for not only trials but practice. Use numbers: 0 for clear, 1 for almost clear, 2 for mild, 3 for moderate, 4 for severe. It’s simple. You don’t need special training, and you don’t need special training to do 0 to 10 on itch and put those numbers every time. That’s really helpful. I recommend trying to get your patients to 0 or 1 for the global score. Mild is definitely good; if they started at severe, it’s great. But the ideal goal is clear or almost-clear skin and 0 or 1 itch given the drugs we have. If they’re consistently scoring at 2 and 3 in the IGAs and 3, 4, and 5 in the itch, you may think they’re doing well, but there’s room for improvement.

Jonathan I. Silverberg, MD, PhD, MPH: Patients often ask me: what are our treatment goals? I’ll say that I want to get them or their child 100% clear skin and itch-free. How much work are we going to do to get them there? How much of a trade-off, in terms of safety or the laborious regimen that we use, are we willing to take for that? When patients hear that, they think, “Wait, I can get clear? For 20 years, I’ve never been clear.” Or for their child, it’s since birth and never gotten better. But it’s possible, and just planting that seed could be so meaningful.

Elizabeth Swanson, MD: It gives them hope.

Jonathan I. Silverberg, MD, PhD, MPH: In clinical practice, what do you use? Are there any formal tools that you’re using to measure, or is it open-ended questions? Do you set specific treatment goals, or do you let the patients do that?

Elizabeth Swanson, MD: For me, it’s open-ended questions and letting the patients tell me when they’re happy. I don’t use anything more formal than that.

Brad Glick, DO, MPH, FAOCD: I apply clinical trials to the real world. The measures Andy is talking about are very practical. I agree. EASI isn’t easy, and PASI [Psoriasis Area and Severity Index] isn’t easy either, but these are very practical numbers. Dr Swanson, you say 0 is doing great and 10 is doing horribly. These are practical numbers. Our patients and even kids are so smart these days. They’re on iPads all the time, so they understand numbers. Their parents clearly understand numbers. That’s how I do it.

There’s some gestalt. vIGA is gestalt. When you’re in a room and seeing someone a month after their therapy, maybe they’re on a systemic therapy or on topicals. The skin is a lighter pink, and the itch is down from a 7 to a 3. Maybe we’re going in the right direction, we can keep moving forward. If it’s monotherapy, then you have that fork in the road. You can bridge to a different topical. But I agree with you, Andy. A lot of our patients are sick of topicals. Just as I say that there’s a biologic era and patients are used to injectables, they’re sick of topicals too. We have to use them, but it would be nice to have a linear treatment plan with 1 therapy.

Transcript edited for clarity

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